Acute low cervical nerve root conditions: Symptoms ... · Acute low cervical nerve root conditions:...

Acute low cervical nerve rootconditions: Symptoms, symptombehaviour and physical screening

Louis Gifford MAppSc.B.ScMCSPSRP

Address for correspondence:Fa/mouth Physiotherapy

Clinic, Kestrel,Swanpool, 'Falmouth,Cornwall, JR11 5BD

E Mail:louisgifford@compuserve. com

This article briefly reviews some theoreticaland clinical issues relatingto both the blatantlyobvious and the easily missed low cervicalnerve root presentations. One of the greatdifficulties rests in knowing whether what wesee and describe clinically, actually representswhat we believe it to be pathologically. Thisauthor freely acknowledges that there aremany clinical observations, speculations andassumptions presented that are open toalternative interpretation. These are myclinical observations and interpretations.

It is proposed that, like many conditions,nerve root problems exist on a c l in i ca lcontinuum, orspectrum, that range from thefull-blown and blatantly obvious to the moreobscure and far harder to detectpresentations. It is as if these obscure andoften minor problems one encounters haveone or two components of familiarity aboutthem but do not have the fu l l compliment offeatures necessary to make a confident clinicaldiagnosis. Cervical nerve root disordersprovide an excellent example of this spectrumconcept Three examples follow:-

1. Medical diagnosis given - 'trapped nerve':'I've got pain from my neck down the arm,it's constant agony, there's numbness and pinsand needles in the thumb and first finger, Ithink I've trapped a nerve in my neck' (eventhe patient has a reasonable concept of theproblem). When examined neck movementsclearly influence symptoms and loss of reflexand segmentally related muscle strength areeasy to detect.

2. Medical diagnosis given - 'Sprainedshoulder muscles'. A 43 year old patientpresents with a 10 day history of vagueshoulder aching pain following a series ofvigorous tennis matches over several days. Hehas normal full range of neck movement andsome s h o u l d e r movements produceinconsistent sharp pains radiating from theshoulder down into biceps., For the patient,the focus is understandably on the shoulderand reinforced when the c l in ic ian f indspositive pain responses to tests thatmechanically load shoulder tissues.One week and three treatments to theshoulder later, the patient is much the sameor worse. The clinician reviews the situationand finds that the patient has in fact had

vague ('of no consequence') feelings ofheaviness in the arm that last about 30seconds when rising in the morning and ashort lasting sharp pain around the medialborder of scapula that he has noticed on andoff for the last 3-4 months. He hadn'tvolunteered these when interviewed the firsttime because he hadn't even thought aboutthem or been concerned aboutthem. Closerphysical examination revealed markedlyreduced triceps reflex and exacerbation of theshoulder ache when the neck was rotatedtowards the side of pain, gentle side flexionadded and sustained gently for 15-20seconds, by 30 seconds the hand paraesthesiabecame evident Sustained anterior palpationof the neck over the ipsilateral C6 nerve rooton the medial aspect of the transverse processof C6 increased the shoulder ache andreproduced fleeting sharp scapula painssimilar to those mentioned.

3. Medical diagnosis given - e.gssupraspinatustendinitis forshoulder pain with positive staticmuscle test, sprained rib muscle for medialscapula pain, carpal tunnel syndrome if handpins and needles only, epicondylitis if pain inforearm etc...Finally, at this lower end of the spectrum, itis not uncommon to have patients that reportsymptom distributions and behaviours thatshow no detectable clinical evidence of lossof conduction but are similar to other casesthat do show such losses. Example 2 abovewith a less dominant pain state and withoutany paraesthesia or loss of reflex would be agood example. Thus, the only way we canassume nerve root involvement is via abalanced analysis of physical tests that relyon pain response and the factthatsimilar paindistributions and pain behaviours are oftenassociated with detectable conduction lossesin other patients. Suspicion of nerve rootculpability is further strengthened when thepatientsuffers later episodes with similar painsthat do reveal conduction abnormalities. Inother words the condition has moved furtherinto the pathophysiological spectrum.

A note on sensitivityNormal nerve roots are generally consideredto be mechanical ly insensitive with theexception of the dorsal rootganglion area (e.g.Howe et a/, 1977; Kuslich et a/, 1991). Axonsof nerve fibres and nerve fibre terminals within

In Touch, Winter 1998 No. 85

Acute low cervical nerve root conditions: Symptoms, symptom behaviour and physical screening

nerve roots may upregulate their sensitivity in response tochanges in their local environment. This may be a result ofdirect mechanical insults, changes in circulatory perfusion orthe inward diffusion of irritative inflammatory chemicals fromdamaged adjacent soft tissues like the disc (for overview, seeGifford, 19973.) (see figure 1). Thus, individual nerve fibreswithin nerve roots may become mechanically sensitive as aresult of local inflammatory mediators perfusing into the roots(e.g. Byrod et a/, 1995; Olmarker ef al, 1993) and/or as aresult of adverse physical forces:- Nerve roots may bephysically injured by extreme spinal movements, or by lessextreme movements in the presence of degenerative changesthat compromise the normal foraminal or spinal canaldimensions. Hence, disc protrusions and extrusions, vertebralapproximation, osteophytes, facet enlargements, synovialcysts, and enlarged osteoligamentous structures like theuncovertebral joints, may all play a part in increasing thevulnerability of nerve roots to adverse postural or movementrelated forces. Thus, the likelihood of roots beingmechanically compromised by normal end range movementsincreases with increasing degenerative change (e.g. Penning,1992; Penning and Wilmink, 1981).

Any space occupying material in the foramen is likely to alternormal circulatory pressure gradients and hence the normalcirculatory, flow through the nerve root. Space occupyingmaterial may be transient- for example oedema or extrudeddisc material (Maigne, 1994), or more permanent, for exampleosteophytes. A significant injuring mechanism is thoughtto

be via compression of foraminal venous plexi, which as a resultproduce a back pressure and circulatory stasis within the nerve(e.g. Olmarker eta/, 1989). Ongoing circulatory stasis may leadto ischaemia and the potential for intraneural oedema,inflammation and fibrosis (reviewed in Butler, 1991; Gifford,1997a) (see figure 1). The potential for this to cause nerve fibreinjury, degeneration and upregulation of sensitivity is self evidentThis knowledge highlights the likely detrimental effects ofprolonged immobility, especially in postures that tend tocompress the nerve roots (see below). It also draws attention tothe fact that direct physical compression of a nerve root is notnecessary for it to be injured and alter its sensitivity state. Forexample, discs.do not necessarily have to directly pinch orcompress nerve tissue to produce pathological changes in thenerve.

Injured or degenerate axons within nerve roots can become sitesdemonstrating enhanced sensitivity as well as sources of ongoingand self sustaining barrages of impulses that result in continuouspains (reviewed in Gifford, 1997b). Zones of abnormal impulsegeneration on axons are referred to as ectopic impulse generatingsites (Devor, 1994; Devor, 1996), since impulses are normallygenerated at nerve fibre terminals and then travel along axons.Sensitivity may be of several kinds:

• Mechanosensitivity. Here pressureand/orstretch on a nerve-produces markedly increased firing and hence pain (Devor, 1994)

(Continued on page 6)

MECHANICAL FACTORS(may be slow or fast)

relatively insensitiveimmediately?

compression of...r

Local vascular system - particularlythe extradural and nerve root venousplexi.

But, if enough force/damage, get signsof altered conduction, e.g. diminishedreflexes, paraesthesia, numbness, weakness

immediate response?

ANTIGENIC/IRRITATIVESUBSTANCES

e.g. leaked nuclear material from disc

ALTERATION IN INTRANEURAL PHYSIOLOGYe.g. oedema, inflammation, fibrosis, nerve fibre damage and dysfunction andthe development of ectopic impusle generating sites.

Figure 1Mechanisms of root injurythat can lead to symptoms.

Pain/Symptoms?

Figure 1: Mechanisms of root injury that can lead to symptoms.



(Continued from page 5)Clinically this means a more or less instantaneous increase insymptoms when nerves are either elongated:- think movements'away' from side of pain and,components of neural tension/neurodynamic testing. Or, when nerves are compressed:-thinkof manoeuvres thattend to 'pinch' nerve, like cervical extensionand movements towards the painful side. Ectopic impulsegenerating sites may not always react in parallel with changesin' the force applied to them (Devor; 1994). Clinically, thismay translate into sudden bursts of pain which instantly go,even if the pressure of the test is maintained, and symptomscontinuing on after the stimulus is removed.

• Ischaemosensitivity (this is speculative: see Gifford, 1997a).Here, sustained compression or stretch on a nerve compromisesneural circulatory perfusion and results in steadily increasingbarrages of impulses from the ectopic impulse generating site.If you think about it,-this happens normally with some nerves• holding the elbow in a flexed position for a long time givesrise to distal paraesthesia in some people. Some of us areclearly more sensitive to this than others which amply illustratesthe great variability of response likely to occur betweenindividuals - whether there is pathology or not. Clinicallypatients with nerves demonstrat ing pathologicalischaemosensitivity develop symptoms overtime but far morequickly than normals do, symptoms are far more intense andincludes pain as well as dysaesthetic symptoms. Phalens' testfor carpal tunnel syndrome is a classic example where the onsetof symptoms in the wrist flexion position may take only a fewseconds to come on and steadily builds up. The same type ofrespotlse is obtained in many acute nerve root disorders whentest positions are sustained (see below).

• Adrenosensitivity. Ectopic impulse generating sites havebeen shown to be capable of becoming sensitive to adrenalineand noradrenaline (Devor, 1994; Koltzenburg, 1996). This isthoughtto be the principle pathophysiological mechanism thatunderpins, sympathetically maintained pain precipitated bynerve injury (overviewed in Janig and Stanton-Hicks, 1996,but see also Gifford, 1997b; Gifford, 1998; and Gifford andButler/1997). Clinically this l i nk of adrenaline like substancesto increases in neural impulse generation helps turn ourattention towards the potential influences of anxiety and stresson pain perception via mechanisms based in peripheral tissues.

As noted above, ectopic generating sites can, of their ownaccord, generate ongoing or intermittent barrages of impulsesspontaneously - when they are termed 'ectopic pacemakersites'. Clinically this may represent ongoing pain which waxesand wanes for no apparent reason or pain that mysteriouslyappears and disappears. Both are very common scenarios fornerve root pains and a source of much concern forthe mystifiedpatient

Ectopic impulse generating sites are also known to be capableof becoming sensitive to many chemical mediators that includesinflammatory chemicals. An injured nerve root that containsnerve fibres which have developed ectopic impulse generatingcapability may well be surrounded by inflammatory chemicalsderived from nearby tissues that have been injured or arepathological. The inflammatogenic potential of nuclear fluidthat has leaked out of the'disc via radial, fissures is a useful

example (e.g. McCarron et a/, 1987; Olmarker et a/, 1995;Saal, 1995). Inflammatory chemicals that derive from adjacentpathological or injured soft tissues may not only give rise toectopic impulse generators but may also play a part inmaintaining their activity.

Symptoms:1. Distribution of symptomsEven in a-classic nerve root disorder, symptoms are usuallydistributed in a vague way - not in neat dermatome patternsand packages that most of the literature on nerve root painwould have us believe. The patient often indicates the area ofsymptoms in a general and imprecise way.Key areas are: the lower neck spreading laterally towards thepoint of the shoulder; the medial border of scapula; the wholeof the scapula; down the back or front of the arm (the patientoften grips the triceps/biceps to indicate the pain area); thelateral or medial forearm and into the hand. Symptoms areoften more intense at particular sites and these are notnecessarily proximal. For example, deep forearm ache that isparticularly intense over the lateral elbow. It is not uncommonfor patients to use the term tennis elbow to help describe theirsymptoms. Another common area of intense pain is locateddeeply along the medial border of the scapula.Importantly, the area of symptom distribution is very variable,can be very patchy and is often hard to localise to a particularnerve root distribution. Thus, when a patient describes theirsymptoms, we should be content with what is described .andworry less about a textbook dermatome that we would wishthe pain to fit into.

Symptoms of paraesthesia do tend to fit more consistently intodermatomal patterns, especially distally in the hand. This isprobably because paraesthesia is felt in the skin and the skinhas an excellent representation in the sensory cortex. In myclinical experience it is fairly common to find that a patientwill complain of numbness/pins and needles in the thumb(classically, C6) yet be found to have a weak triceps and/ordiminished triceps reflex (C7).Other areas of symptoms that further challenge dermatomalpattern thinking include: C6 or C7 nerve roots having vaguepain in the axilla area frequently radiating down onto the lateralchest wall and even spreading anteriorly into the pectoral area.Axillary pain with cervical nerve roots is very common.Symptoms may also be reported in the anterior neck, clavicularand pectoral area.

At the lower end of the spectrum, symptoms may be foundalone or in combination in any one of these areas and theremay be no symptoms anywhere near the neck. Examples aredeep intermittent aching in the biceps or triceps region andoccasional sharp shooting pains in the lateral forearm. It maybe an annoying localised burning pain or itch in a small areaalong the medial scapula border that keeps them awake atnight accompanied by an annoying heaviness and tiredness ofthe ipsilateral arm during the day.

2. Symptom qualitySymptom quality and behaviour may be a key definingfeature(Figure 1) of pain that has neurogenic origins. Classic nastynerve root presentations often describe their pain as a




(Continued from page 6)horrendous tooth-ache like pain in the arm. The pain can beghastly, unrelenting and extremely wearing, even for the moststoical and uncomplaining of people. Patients are desperatefor help and it is very tempting for clinicians to do desperatethings to help them out of their misery.

Some patients complain of sharp shooting pains or 'knife in'pains, anywhere from the neck across the shoulders to downthe arm. Sharp shooting pain may manifest on its own withoutany ache. Again the shooting pain can be ghastly, the patientclutching the area of pain and strongly wincing for many secondsas the 'after' pain gradually subsides. Shooting pain withoutany accompanying ache seems more common in elderlypatients and often occurs for no apparent physical reason -hence shooting pains occurring at rest, whatever the position,or occurring one moment with -a neck movement the nextwith an arm movement Patients understandably are oftenvery worried, even frightened by these ghastly and mysteriouspains. It is very easy to see why patients often view theircondition in terms of serious pathology.

Paraesthesia and numbness have already been mentioned.They are usually fairly well localised.

Symptoms are occasionally more bizarre. For example, feelingsof crawling, trickling and sometimes extremely uncomfortable'gripping' sensations.

A very common description of the arm is that it feels 'heavy','leaden' or 'tired and useless' a lot of the time. The kind offeelingyou get when you continuously overwork a muscle' is acommon description.

At the lower end of the clinical spectrum similar words (ache,sharp, knife, heavy, dull, tired) are used to describe thesymptoms but the intensity and frequency is far less. Wordslike 'annoying', 'distracting' and 'irritating' are used. Whilethis is not difficult to fathom, what is, is the difficulty the patientoften has in tying the symptoms to particular things that theyhave done. An appreciation of ectopic impulse generatingsites' capacity to develop sudden and spontaneous activity helpsin the understanding of these types of phenomenon.

3. Symptom behaviourTime-24 hour behaviourAcute nasty nerve root symptoms may be constant andunrelenting with the resultthatthe patient gets very little usefulrest or sleep. Many patients report pain far worse at night andyet that they can manage during the day when on the move ordistracted by their daily tasks.

Patients with less severe nerve roots show huge variability over24 hours having no particular time related pattern from oneday to the next However, many do report having troublesometimes during the night too. Night symptoms are a commonfeature of many peripheral neurogenic disorders, recall thepersistent night problems that patients with carpal tunnelsyndrome report

As nerve root syndromes recover they can often ease upsignificantly for a few days, with the patient greatly relieved,

but then return with former severity, adding much to thepatients concern. It is worth warning the patient of thislikelihood so that they know what to expect. Improvementoften involves lurching from several good days to several bad,but as time goes on the flare-up times get shorter and shorterand less intense.

Symptom behaviour related to posture and movements

Patients suffering nasty acute nerve root pains rarely findconsistent positions of relief and if they do they are onlycomforting for a brief period of time. A key feature is that thepatient become restless in their quest for relief and greatlyappreciate an understanding of this problem. The doctor toldme to take paracetamol and lie down and rest for T O days';The last physio insisted I sat up straight and kept my neck inperfect posture I'm sorry 1 just can't keep it up - at first itsbetter for a short while then I have to move and get relief bybending my neck forward'.

Acute low cervical nerve root disorders may find short termrelief in the following ways:

• Arm overhead - relief lasts for short periods in most casesand patients are forced into this position frequently if theyhave to sit for long - e.g. driving the car - one hand on wheelwhile the affected side arm is raised with the hand resting onthe head. This has been called the 'shoulder abduction reliefsign' (Beatty et a/, 1987; Davidson et a/, 1981 ;• Fastet a/, 1989)and has been shown to significantly reduce intraforaminalpressures on the C5, C6 and C7 nerve roots in fresh cadaVers(Farmer and Wisneski, 1994). The mechanisms these authorsproposed forthisare: First, the shoulder abduction may causethe intervertebral foramen to enlarge therefore reducingpressure on the sensitised nerve root. Second, the abductedposition reduces the tension on the nerve root While thisseems to fly in the face of thoughts about classic neural tensionmanoeuvres - that use arm abduction to add neural tension, itshould be appreciated that normal arm abduction allows thescapula to elevate and rotate towards the spine. Hence, thecoracoid process may move several centimetres closer to theneck thus allowing considerable slack into the brachial plexusarea and nerve roots (Davidson et a/, 1981). All standard upperlimb tension tests (ULTTs) either preventthe scapular elevationoccurring or add in scapular depression before the armabduction component is added (see Butler, 1991).

From this one would expect that the patient would gain similarrelief from sustained shoulder shrugging or sitting with plentyof pillow support along the forearm so that the whole arm/scapular unit was raised into elevation. Surprisingly, this doesnot always occur suggesting that either scapular rotation isneeded as well, or, relief by reducing root tension or pressureis only one possible explanation behind the'shoulder abductionrelief position.

Postures and movements into flexion and away from theside of pain.Patients with classic nasty acute cervical nerve root disordersadopt postures that flex slightly and deviate away from theside of pain. Moving towards the side of pain or into extensionis often very provocative if the nerve is in an extremelymechanosensitive state (immediate pain with movement). Thisclinical finding fits with knowledge that the intervertebral



foramen of the low cervical roots enlarge in flexion andmovements away from the side of pain and diminish inextension or movements towards the symptomatic side (Ehniet al, 1990; Yoo et al, 1992). Thus, movements that decreasethe size of the foramen tend to compress and increase pressureon the roots, and movements that increase the foramen sizetend to decrease pressure on the root (see Farmer and Wisneski,1994). Interestingly, Farmer and Wisneski (1994) notedunpredictable results in their pressure change observations incervical flexion. For example, C5 and C7 roots demonstratedmodest increases in pressure in flexion and C6 showed modestdecreases in pressure. It appears that the actual pressureexerted on the nerve root is not wholly dependent on changesin foraminal sizes in flexion positions. Proximal and distaltethering effects by variable intraspinal and extraspinalligamentous structures that may tether the roots; movementsof dura relative to the often angulated course of nerve rootswithin the spinal canal (Nathan and Feuerstein, 1970); posturaleffects on circulatory supply, and the position of the shouldercomplex and arm are the sorts of issues that need to beconsidered too. Whatever the biomechanical findings fromthese few cadaver studies, in the clinic it is very common tofind patients getting relief by adopting varying angles of neckflexion. It may be that there is.far more significant reductionof root compression in flexion in the presence of local swelling,or a disc bulge, herniation or frank protrusion.

Extreme cervical flexion in lyingSome patients find that the only position that they can getcomfortable enough to get to sleep in is by lying supine and

having 2 or 3 pillows wedged behind the neck to maintainend of range flexion. While this goes against many principlesof physiotherapy management it can be seen as a very adaptive'nerve saving/pain relieving' position to adopt dur ing the veryacute phase of the disorder Hurryingto restore normal posturemay often maintain pain (and possibly increase neural damagetoo) for longer than it otherwise would if left to 'natural' wellingrained reflex antalgic postures that have survived the test oftime.

• Postures and movements towards the side of pain.It seems that there are a small percentage of cervical nerveroot disorders that get relief by adopting postures deviatingtowards the side of pain. Although this appears incompatiblewith thoughts of foraminal compression it may be that somerelief in root tension is achieved. In-keeping with this is theclinical f inding that the majority of those patients who preferdeviation towards the side of pain tend to have a very clear cutand positive response to ULTTs. In these cases, the neuraltissue appears to be more sensitive to stretch than compression.

Patients with less obvious or more minor root problems oftenhave great difficulty in identifying any clear relieving posturesor movements. The level of symptoms simply may not demandit orthere may be insufficient or inconsistent mechanosensitivityfor the patient to make sense of any particular movement orposture that may be provocative. Delay in symptomprovocation - as suggested by ischaemosensitivity, further


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(Continued from page 9)detaches the perceived connection of a symptom increase froma provocative movement or posture.

Occasionally, odd arm positions that may include arm elevation,cervical postures in flexion, deviation away or towards, andrarely, cervical extension are reported. This type of informationfrom patients with odd presentations can provide useful hintsfor the inclusion of an investigative focus on themechanosensitivity of the low cervical nerve roots.

If all else fails, the most common methods of relief come downto protective use of the part where the pain is felt, somethingwhich may draw our clinical attention away from proximalnon symptomatic areas and towards the painful tissues as theprimary source of the problem. It is important to bear in mindthat mechanical effects on nerve roots can be altered by armpostures. Thus a patient may well findseveral arm postures that provide adegree of relief, even posturesinvolving the unaffected arm.

under a shower. .Sitting, especially slumped postures withforward head positions that promote low cervical extension,commonly aggravates the symptoms. Analysis often revealssignificant and often sustained low cervical extension and thatminor alterations of posture quickly or slowly change symptoms.

All positions and activities that patients volunteer as beingprovocative are worth analysing with thoughts of neuralcompression or neural elongation effects (see below). Forinstance, patients often report being able to lie comfortably onone side but not on the other. Analysis of the number of pillowsused combined with thoughts about compression/elongationcan be useful. Thus a right sided nerve root problem that ismainly provoked by root compression postures/movementstends to be more comfortable lying on the right side if thepillows are sufficient to side flex the head to the left. Whenthe patient turns onto their leftside, with the same number of

Even in some classic nerve rootconditions, patients may not associatedominant peripheral symptoms withneck postures and movements.Frequently patients have quite normaland free neck movements butconsiderable nerve root pain. It oftentakes a good examination andexplanation to convince the patientthat the primary source is proximal andrelated to enhanced neural sensitivitywhere the nerves enter and leave theneck.

The following postures andmovements are frequently found toexacerbate the symptoms of acutecervical nerve root disorders:• Looking up and extending theneck, sustained postures involvingextension, cervical retractionexercises, and movements towardsthe painful side.One of the most consistent aspects ofacute low cervical root syndromes isthe production and provocation ofsymptoms with cervical extensionmovements, exercises and postures.This clearly fits with the decrease inforaminal dimensions reported earlier.The presence of extruded or bulgingdisc tissue, or any. space occupyingpathology, will obviously enhance thiseffect. Patients often reportprovocation of symptoms whenperforming activities like shaving, lyingsupine in bed with a single pillow, lyingprone with the head in full ipsilateralrotation, swimming with the^head upand hair washing in neck extension

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pillows, the neck side-flexes towards the right, compresses theroots and hence tends to exacerbate the symptoms. Patientsoften find it odd that they are more comfortable lying on thepainful side rather than off it. This type of thinking can helpexplain the apparent paradox.

Movements away from painful sideThis response fits with the cluster of patients who present withsymptoms relieved by postures towards the painful side andwho have positive neural tension/neurodynamic tests, i.e.'neural elongation' root sensitivity.

• Flexing the neck.While many patients report relief in flexion, if the movementis taken towards the limit of range, symptoms may be furtherprovoked. End range flexion occasionally provokes distal/armsymptoms but more commonly produces local neck and yokearea related discomfort. A small proportion of presentationshave all symptoms severely brought on inflexion -these patientsare usually extremely limited in most cervical movements andmost of the tests discussed below are found to be positive too.

• Arm movementsPatients with arm pain of root origins frequently reportdifficulties using the arm. Closer scrutiny usually reveals a veryvariable stimulus response relationship. Again, analysis shouldbear in mind neck posture and the effects of arm/shoulder/scapula posture on neural tension/elongation. Increased painas a result of carrying shopping can be interpreted in terms ofincreased neural tension on the hyperalgesic roots. Positivepain responses to distal joint and muscle testing may reflect asecondary hyperalgesic state rather than any localised primarylesion (see below).

4. Other factors to consider:

Up to date clinicians should be aware that barrages of impulsesarising from ectopic generating sites on peripheral nerve or asa result of nociceptor activity following tissue injury will causechanges in the central nervous system processing of normalsensory input from normal tissues (e.g. see Gifford, 1997b;Gifford and Butler, 1997; Johnson, 1997). Barrages from ectopicimpulse generating sites are particularly spiteful. These centralnervous system changes resultin the phenomenon of secondaryhyperalgesia whereby normal inputs from normal tissues getprocessed in the central nervous system in terms of pain, ratherthan innocuous sensations. The clinical significance of this isthat many tissues that produce pain when physically tested bymanual therapy techniques using physiological movements,static muscle tests or palpatory pressures may be relativelynormal.

Thus, nerve root injury may easily result in 'false' positivefindings in examined peripheral muscles, nerves, joints, skinand any other soft tissues in areas segmentally related to thenerve, and in extreme/severe cases, tissues well beyond normalsegmental limits. Physically testing or pressing on a particularstructure and reproducing the pain the patient complains ofdoes not therefore mean that the definitive source of the


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(Continued from page 11)problem has been found (see Gifford, 1997b). All any 'positive'test response does, is reflect the sensitivity state of the tissueexamined - it may or may not be significantly pathological (seenext section).

For example a 34 year old patient complained of having aheavy tired arm with a low grade and fairly continuous forearmaching sensation that was starting to disturb his sleep. Hismajor concern was a knife like pain well localised about onethird of the way down the medial scapula border on the sameside. The problem was about 2 weeks old and described asworsening and becoming worrying. He had had 2 sessions ofmanipulative treatment for the scapular pain. This involved'firm' neck and thorax 'cracking' but to little effect other than afeeling of freedom of movement for several hours. The armproblem worsened about 4-5 days after his last manipulationsession. On examination the medial scapula area feltthickenedand tight compared to the other side and modestly firmpalpatory pressures exacerbated the arm pain within 15 secondsorso. Was this the source of the problem? .It clearly was to thepatient, but there were further striking findings to be takeninto account The patient had no triceps reflex on the affectedside and the triceps muscle was markedly weaker to theastonishment of the patient Neck movements were normalexcept end range extension which brought on a vicious 'bite'of pain in the medial border of scapula. The patient wasunaware of this f inding until testing. Anterior palpation of theneck over the ipsilateral transverse process of C7 alsoreproduced the scapula pain and increased the forearmdiscomfort. ULTTs were unrevealing.

Taking into account results like this adjusts the focus of attentiontowards nerve dysfunction at the C7 root level and relegatesthe medial scapula tenderness more to asecondary hyperalgesiastatus with the possibility of secondary changes (swelling andthickening) influenced via efferent neurogenic signalling andsecretions (for good overview see Hasue, 1993). In fact, furtherpalpatory investigation of this patient revealed widespread andsignificanttenderness overthe lateral epicondyle of the elbow,the radial nerve in the radial groove and the belly of thesupraspinatus muscle where medial border of scapular paincould again be reproduced. Skin lighttouch comparisons withthe non-symptomatic forearm revealed skin hypersensitivitytoo. Overpressure to glenohumeral flexion and elbow extension

• produced markedly more discomfort when compared to similarcontralateral overpressures. A more cursory examination, orone that is wholjy biased to a single tissue approach is likely tomiss significantfindings that add to the likely nerve rootoriginsof the problem and the appreciation of altered processing factorswithin the central nervous system. There are great reasoningerrors in assuming that just because a tissue palpated or testedreproduces a patients pain it has to be the 'source' of theproblem. Pain distribution and pain response to testing areoften very misleading, even in acute conditions like these. .

Physical screening:There are not many formerly recognised tests for cervical nerveroot dysfunction and I am only aware of three that have beensubjected to reliability and validity testing (see, Viikari-Junturaet a/, 1989). These tests are Spurling's test, axial manual tractionand the shoulder abduction test Spurling's test - neck

12

extension, rotation towards add compression (Spurling andScoville, 1944), is pain provocative, while the other two areheld to be positive when pain is relieved. These researchersattempted to include the brachial plexus tension test butunfortunately discarded it from validity analysis because of poorinter-examiner reliability (see Viikari-Juntura, 1987). Whencompared to the simplicity of the SLR, the ULTTs may be fartoo demanding of manual dexterity to be usefully repeatablefor untrained researchers. The fact that intra and extra examinerreliability has been repeatedly shown for these tests meansthat researchers either need better training, or the use of asimplified version of the ULTT (see below)!

The three tests above were shown to be highly specific forcervical nerve root disorders (Viikari-Juntura et a/, 1989 ). If atest demonstrates high specificity, a 'positive' response willalways 'rule in' the diagnosis. However, although the threetests showed high specificity, they unfortunately showed lowsensitivity. When a test demonstrates high sensitivity thediagnosis can be confidently ruled out if the test is negative.Thus, because the three tests have a low sensitivity value, whenthey are not positive on a given presentation it does notnecessarily mean thatthe nerve root is normal. Many abnormaland highly sensitive nerve roots do not have a positive Spurling'stest and do not show a lessening of symptoms with the armabduction ortraction tests. On the other hand, if the tests arepositive the clinician should have increased confidence thatthe nerve root is a highly likely source. Note that these testswere deemed positive in relation to changes in 'radicularsymptoms in the forearm-hand' (Viikari-Juntura et a/, 1989).The clinician should appreciate that Spurlings test, for example,physically challenges a great many tissues in and around theneck. Thus producing local pain with this test may have moreto do with local soft-tissue sensitivity rather than with nerveroot pathology/sensitivity. Thus, the key confidence enhancer,is alteration of distal symptoms.

This research based approach serves as a useful challenge toour clinical reasoning skills which are so often clouded by biasto a favourite theory or test protocol. The rational and openminded clinician wisely sees other possibilities dur ing testing,especially when tests rely on symptom responses and physicalstrain on multiple tissues. For example: if an SLR reproducesa patients back and leg pain it is faulty reasoning to say that anerve rootmusf. be demonstrating enhanced sensitivity as theSLR influences many other structures that could well be partlyor wholly culpable too. It is also faulty reasoning to assumethat if the SLR and slump test did not reproduce this person'sback and leg pain it cannot be a sensitised nerve root It couldstill be related to nerve root but due to anatomical anomalies,root tethering, lack of range in some joints, protective spasmby hamstrings etc. the mechanical effects of the SLR may notreach the sensitive segment of the nerve root. In addition,i n j u r e d nerve may be sensitised but not necessarilymechanically sensitised, or not mechanically sensitised toelongation/stretching forces. The irrational dominance of oneparticular test (like a positive SLR or ULTT or palpationreproducing symptoms) in deciding whether a particularcondition is present or not means that many patients are oftendenied adequate investigation and management options, orare subject to unnecessary invasive procedures.



Reliance on pain responses to physical testing to giveunequivocal tissue based diagnostic power is not really tenable.Positive pain responses to physical tests merely builds-up an'enhanced sensitivity' picture of various tissues considered tobe influenced by the test procedure. Clinicians are urged toconsider that pathobiological mechanisms responsible for painare extremely complex and go far beyond the tissues examinedphysically (Gifford, 1998b; Gifford, 1997b; Gifford and Butler,1997). The safest conclusion of any test is therefore that thetissue(s) under consideration are demonstrating an enhancedsensitivity state (hyperalgesia/allodynia) and may or may notbe 'pathological'. Even if there is pathology in the tissues thismay still have little bearing on the outcome of the condition orthe response to treatment.

The next section presents a series of tests and a conceptualapproach to testing whose formal purpose is to gather evidencethat can be scrutinised and weighted before a diagnostichypothesis is made with regard to a sensitised low cervical nerveroot. Many of these principles can be applied to lumbar andthoracic nerve root disorders too.

Nerve root testing rationale• When performingany physical movement or test procedureit is simple to think: Is this test compressing the motor elongatingthe root? The recent wave of enthusiasm for neural tensiontests has rather sidelined thoughts of tests thattend to compressneural tissue. Combinations of compression and elongationare of course possible. For example, the median nerve in thecarpal tunnel will be elongated and compressed when the handis taken into wrist and finger extension. Performing an ULTTwith the patient's neck in extension and ipsilateral rotationcan also be viewed as having elongatory and compressivecomponents..

The subjective examination should provide clues as to whethera root problem has a bias towards provocation by neuralcompression, or provocation via neural tensioning. For exampleif movements, activities and postures that provoke pain areanalysed as being more towards the painful side or intoextension, expect more of a 'compression' sensitivity type.

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• Note the timing of the pain response to a test. Is itimmediate? If so then it can be assumed that the tissue(s)undertestare demonstrating enhanced mechanosensitivity. Ifsymptoms take a while to appear and slowly build up andspread, the pain response may relate more to anischaemosensitivity. Cervical nerve root syndromes are oftenslowly increased by sustained ipsilateral-rotation. The longerthe position is held the more intense the pain becomes andthe more it tends to spread distally and involve all areas.Sometimes the pain is described as slowly 'oozing' down thearm in tandem with slowly increasing symptoms of paraesthesia.A problem with this simple division between ischaemosensitivityand mechanosensitivity is that symptoms often come onimmediately and build up and up anyway, even after the testis completed. Ectopic impulse generatingsites may only requirea brief mechanical stimulus to initiate a cascade of ongoingimpulses that can take many hours to settle. (This is discussedfurther in: Gifford, 1997a).

An issue of particular importance is the potential of end rangetests, many manual therapy techniques ortherapeutic exercisesto harm or severely irritate a nerve without any clear or majorpain response at the time. Mechanosensitive peripheralneurogenic problems of all types are frequently much worseafter physical examinations and treatments - even though theyappear to respond well at the time in terms of pain reductionand phenomenon like pain 'centralisation'. Devor (1994)highlights the important laboratory finding that nociceptive Cfibres may only develop significantspontaneous ectopic activitydays or even weeks after the injury process. Thus, injury now,may mean worsening symptoms in several days time'. Relyingon instantaneous pain response for treatment efficacy needsto be done with caution.

Physical screening aad analysis:For descriptive purposes physical screening analysis has beendivided into two phases. The experienced clinician can skilfullyshift back and forth between the two phases and selectivelyfocus on particular aspects at any given time.

Phase 1:Neurological examination essential (see below).

Movement overview:Begin by briefly observing posture, gross movement qualityand ranges. Look for tentative movements, non-detailedsymptom responses and major or minor abnormalities in rangethat may be focused in on later.• All cervical movements• All glenohumeral movements

All scapula movements• Forearm and hand movements• Other movements, for example provocative or relievingpostures and movements that the patient has alreadymentioned.

Phase 2:Specific physiological tests:• For all tests below, if appropriate: add overpressure gently,if no response-sustain up to 15 -20 seconds. Sustaining up to


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(Continued from page 13)45 seconds has been advocated for peripheral neuropathy (seeDurkan, 1991).• For test responses to more strongly add weight to a nerveroot'focus'they should particularly bring on distal symptoms,orsymptoms in tissues not physically influenced by the testing.• The direction taken for closer scrutiny depends on priorknowledge of provocative movements - i.e. from the movementoverview above and from features of significance in thesubjective examination. For simplicity the condition may bedivided into neural compression type or neural elongation type.• The order of the tests given is the rough order in whichthey may be performed. The key to the approach is maximalinformation with least force and least potential provocation tothe sensitised nerve root. Obviously it may not be necessary toperform all tests. .

Nerve root demonstrating 'compression' sensitivity: Oneor several of these tests may alter symptoms:

Patient Standing:• Shoulder abduction test, often done first and classicallyrelieves symptoms.• The active LJLTT (may or may not be provocative with'compression' type). This looks at relevant components. Forexample the effects of active scapula elevation and depressionwith elbow extension or flexion. In a more precise way, facethe standing patient, and give the patient the followinginstructions while you also demonstrate the components: 'Keepyour arm by your side, keep your elbow braced comfortablystraight, hands and fingers straight, now reach downwards byletting yourshoulder drop, extend your wrist and fingers back,now keep all that on and slowly take your arm out to the side....'It may only be necessary to go to very early stages of the testwhich should be performed very slowly and carefully. Neckside flexion can be added in at any of the stages.

It is my opinion that in many circumstances the patient, iftaughtwell, can be far more accurate in establishing and main-taining joint positions for complex tests like this than can beachieved by purely passive testing.

It is always best to perform the test on the non-symptomaticside first - it provides practice and it can also be used as aninstant comparison by the patient I often say to the patientsomething like: The next test tests the nerves in your neckand arm for their sensitivity to being stretched slightly. Itnormally produces some sensations of stretching or pulling inthe arm and occasionally the hand. Before doing it on yourbad arm I am going to get you to perform the test movementson your good arm so that we can find out what your normalresponse is to compare to the bad side in a moment... If youget any sensations let me know what they are and where andremember them so as to compare when we look at the badside'.

Figure 2: Examination of cervical spine: Right rotation plus right side flexion tends tocompress the right low cervical roots in the intervertebral foramen.It will also elongate the roots on the left side. (Reproduced, with permission, fromButler and Cifford 7998 The Dynamic Nervous System. NO! Press, Adelaide.)

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Figure 3: Retraction plus low cervical extension - bilaterally narrows the lowcervical intervertebral foramen and can be very provocative for low cervicalnerve roots that have become mechanically sensitised. (Reproduced, withpermission, from Butler and Cifford, 7998, The Dynamic Nervous System. NO1

Press, Adelaide.)

In the roots demonstrating dominant 'compression' sensitivitythere may only be minor differences between sides for thistest or any of the ULTTs. This is rather like a sciatic problemhaving relatively normal range and sensitivity of SLR and slumptest, yet symptoms easily provoked by movements and pos-tures involving extension.

• Patient Sitting• Rotation towards.• Sideflexion towards (if necessary making sure that the lower

cervical spine is moved)• Rotation towards plus side flexion towards (figure 2).

Extension. (Extension plus rotation or side flexion towards- rarely used)Retraction.



• Retraction plus low cervical extension (figure 3).• Other movements and combinations of in detail if necessary(in good clinical reasoning it is necessary to investigate in termsof pathological sources as well as in terms of the extent of thesensitivity - clinicians need to know all the tissues andmovements that are sensitised in order to appreciate the extentof the impairment and to be able to plot its response tomanagement/treatment inputs over time).

Patient supine:• Cervical traction (classically relieving) often done whenpatient first lies down - see below.• An appropriate ULTT. In compression type nerve rootsULTTs surprisingly show only a moderately enhanced sensitivityresponse when compared to the contralateral side. Alwayscheck it and check the effects of sustaining it just like the othertests. Note the 'active' neurodynamic test described above.• Anterior palpation over the exiting nerve root

In my experience the above tests are all that are necessary.However, if you are still suspicious and wish to examine morefully the test progression can be taken further:-• Sitting:• Cervical compression in neutral.• In rotation towards, plus side flexion towards add cervicalcompression. Or, Extension plus rotation towards addcompression -Spurlings test Both are similarto the low cervicalquadrant position described by Maitland (1986) but with theaddition of compression.

The addition of compression in this test should be performedwith great caution and in my experience is unnecessary and

certainly not worth risking in the great majority of acutepresentations. It is not at all comfortable for normal necks andif there is_ any degree of degeneration/underlying sensitivityeven the gentle application of this test may actually precipitatea nerve root condition, or strongly aggravate and extend thetime to resolution of a relatively minor one.

• Lying:• Many combined tests can be engineered: e.g. neuraltension tests with neural compression. For example, patientsupine in side flexion towards, add ULTT. Unilateral antero-posterior palpation in side flexion towards. Experience dictatesa very careful approach to prone palpation and the proneposition, in acute and reactive, or potentially reactive, cervicalnerve roots. The extension it induces may actually provokeradicular symptoms in the arm with neurological deficit.

Usually relieving tests:Both the following tests have high specificity (see above) andare far less threatening to the nerve rootthan Spurling's test• Manual cervical traction in supine. I Suggest great care withthis test in very acute, highly reactive and early cervical nerveroot disorders. Cervical traction, even very gently applied maybe relieving at first but intensely provocative a short whileafterwards. Care also with assuming that just because a fewmoments of manual traction are dramatically relieving, thattraction treatment will be helpful. While it often is useful,there are many who are made significantly worse by it -especially if the pull is into extension. Again, relief of distal'radicular' symptoms by traction provides the strength to thistest


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(Continued from page 15)• Shoulder abduction test-the patient simply places the handof his affected arm on top of his head. It is often useful toexplore the effect of isolated shoulder elevation and depressionon symptoms (see 'active ULTT' above). For instance, if painis relieved by arm overhead one would be interested to see ifactive scapula elevation and depression influence symptomstoo. A majorfocus of the first encounter with the severe nerveroot disorder is to f ind as many options for relief as possible -especially with regards to help with sleeping.

Nerve root demonstrating 'elongation' sensitivity: One orseveral of these tests may alter symptoms:The examining sequence can be much as that above but withemphasis on seeking responses that elongate the root tissues,i.e. movements away rather than towards. The following testsare of particularly interest:• Shoulder abduction test• Active ULTT• Cervical movements away.• Combining movements can often be helpful. Forexample,rotation away plus side flexion away, or scapular depressionwith arm by side plus rotation or side flexion away.

Neural tension tests. There is generally no great need toopt for any particular one of the four standard ULTT tests asthey do notspecifically tension any particular low cervical nerveroot with precision. Thus, even a clear-cut C8 nerve rootdistribution into the medial side of the hand which tends tomake clinicians think 'ulnar nerve therefore ULTT3' can stillbe easily provoked by standard ULTT's biased to the medianor radial nerves. A simple and quick passive way of examiningthe sensitivity of the low cervical nerve roots that might becalled the 'upper l imb SLR' is: (described for right sidedproblem) patient supine, neck with or without a pillow (bestwith to avoid extension); stand to the right of the patient andface patient, slide your right hand under their right scapulaand gentry bring the scapula into depression; the left hand allthe while holds the extended arm atthe elbow; now passivelyabduct the arm - if necessary the patient adds active wrist andfinger extension to further sensitise the test This last componentis the equivalent of ankle dorsiflexion in the SLR. The test caneasily be repeated after placingthe neck passively in sideflexionaway (towards the left with the right sided problem). This ishow I have taught all my local GP's who are interested toperform the test. I know it sounds patronising, but does takephysiotherapists many hours of practice to become proficientatthe ULTTs - they are complex and difficult tests to performwell. The simpler tests become, the more likely they are toshow widespread validity.

A few notes on neurological testing:• A neurological examination at every visit is essential.• There are many therapists who would argue that reflextesting/neurological testing is unnecessary when symptoms areproximal only. I would strongly recommend that reflexes andmuscle power are routinely performed in all presentations whenfirst seen. For example, loss of triceps or biceps power and/orreflex in a patient presenting with two days of local medialborder of scapula pain and a referring diagnosis of local musclesprain. It is not uncommon to find normal biceps or tricepsreflexes but marked loss of power, if it is feasible, therefore,always try to test both.

16

Lack of reflexes is a common f inding in the older patient,especially reflexes relating to roots that exit from segmentsnotorious for degenerative changes. An important pointtoo isthat pathological changes do not have to hurt. Histologicalstudies of humans at autopsy show that 50 percent of thosewho have no record of ever complaining of symptoms haveconnective tissue changes and nerve fibre changes in neuraltissue, particularly in vulnerable places (Neary et a/, 1975).

If the patient is in considerable pain and/or anxious aboutoverstraining causing further injury, static testing for musclepower may be impossible to adequately examine. Pain/anxietycan dominate the presentation to such an extent thatconclusions with regard to muscle power may be quite difficultCheck for scapula 'winging' which may occur with C6 or C7nerve roots (serratus anterior is innervated by the long thoracicnerve whose derivations are mainly C6,7 roots). Check formuscle atrophy, for example, observe the suprascapular andinfrascapular (supraspinatus and infraspinatus), and deltoidareas for C5-6; the posterior arm (triceps) for C7; the thenareminence for C8 and between the thumb and index finger forT1 (first dorsal interosseous) (Ellenberg et a/, 1994). Bear inmind that obvious 'muscle wasting in an acute nerve root painof only several days, may not relate to the current episode(although it sometimes does). The wasting may be the resultof a well established and ongoing'silent' neuropathy that hasonly just become symptomatic, or may be an indication ofsignificant root compression or quite serious pathology. Takeinto consideration the age of the patient, the degree of likelydegeneration (stenosis) and whetherthey have had any previousneck injuries or nerve root problems that could account forthe wasting.

While pain distribution and pain behaviour give good clues asto the type of pain mechanism operating (Gifford,1997b) theyrarely give accurate clues as to the exact level of rootinvolvement. Since there is apparently far less overlap inmyotomesthan dermatomes, muscle weakness, if it is present,rather than sensory change or loss, is likely to be the mostreliable guide we have as to the segmental origin of a rootdisorder. Interpretation of muscle testingfindings must of coursetake into account the patient's willingness to produce a f u l land firm contraction.

A final comment:The recent CSAG report for low back pain (CSAG, 1994 p54-55) presents a diagnostic triage that divides back relatedproblems up into three: 'simple backache', 'nerve root pain'and 'possible serious pathology'. It recommends a differenttherapeutic approach for each. This is commendable, butfurther scrutiny reveals what I believe to be quite an inadequateand simplistic presentation of the clinical features of the lumbarnerve root condition. My prime concern is that it representsonly the classic end of the clinical spectrum and if adhered to,many very common atypical presentations wil l be incorrectlycategorised. This can mean inappropriate management andmuch misunderstandingforthe patientwhose condition is oftenvery resistant or worsened by standard treatment approaches.It seems highly likely that similarly inadequate diagnostic'features' wi l l be applied to cervical root disorders whosepresentations, I believe, can be even more difficult to fathomthan those relating to many lumbar nerve roots.

(Continued on page 19)In Touch, Winter 1998 No. 85

Can/a solicitor derfiand a copy oft a self employed privatepractitioner's notes under the above act?

'This area ha^ long been a/problematical one for members,There is ar/increasing trend for solicitors to ask for notes to/De

Orthopaedic surgeons in order that the surgeon in/n can compile arnedical report. This practice has grown

(3. matter of custom and goodwill without anvôund legalba/ls. The purposes the physiotherapist's notes/is-to facilitatene care, treatment and support of the patient and from a

/practical view/mey are an integral part of gare and are a toolavailable to the practitioner.

There is i/b doubt that the notes remain the property of thphysiotherapist concerned who is/not bound to automaticallycompl/with any request for t)tfem offering a report iiWead,produced forthe appropriate/fee. Indeed this avenue rnay wellbe/preferred once the/solici tor understands/that the

ysiotherapist rnay not feel able to "support/any report/reduced by a third/party from an interpretation of the

/physiotherapist's clinical records.

To return to the jriitial question, OCPPP'sôlicitors advise thatthey would argye that member's records'fall underthe followingsections of the act as detailed belowXnd as such access is ableto be demarided.

Physiotherapists are specificall/referred to in the Act as "healthprofessionals"

Section 1 "Health Record" and related expression^(1) In this Act "health record" means a reco/d which-(b) has been made by or on behalf of a health professional

inconnection with the carôf that individual.(2) In this Act "holder"/in relation to a health record,means- (C) in any other case, the health professional bywhom or on whose behalf the record is held.(3) In this Act/patient", in relation to a health record,means the hmividual in connection wijt-h whose care therecord has been made.

Our solicitors do not believe that a/member would be able toargue that rights of access may be partially excludecFu/lTiermore, there is a fee thOT can be charged but not/one

Kceeding the maximum prescribed under section 21/ofthe' Data Protection Actl 984r (£10 Jan 1998) A fee can ̂ chargedfor copying the recorcKor extract but it must not/exceed thecost of actual copying together with the cost o/postage.

As stated abo*4, once a solicitor understands that thephysiotherapist may not feel able tp^'support" any reportproduced/by a third party from /cfn interpretation of thephysiotherapist's clinical records, they may well prefer the safet;

-provided by the production ofXreportbythe physiotherapist

The medico-legal asperts of physiotherapy is of/growingrancern and OCPPPare'working closely with the/GBP and the

'Medico Legal speciaLmterest group to formubfe and provideguidance for members.

Your attention is'also drawn to the CSP/rnformation PapeXPA2"Access to Health Records". This is arailable directly from theCSP or OCPPP.

Please send an A4 stamped addressed envelope with yourrequest

(Continued from page 16)References:Beatty, RM, Fowler, RD and Hanson, EJ (1987). The abducted arm as a sign of ruptured cervical disk.Neurosurgery 21: 731-732.Butler, DS (1991). Mobilisation of the Nervous System, Churchill Livingstone, Melbourne.Butler, DS (1996) Personal communication.Butler, DS and Cifford, LS (1998). The Dynamic Nervous System, NO1 Press, Adelaide (In press).Byrod, C, Olmarker, K, Konno,S, Larsson, K, Takahashi, K and Rydevik, B (1995). A rapid transportroute between the epidural space and the intraneural capillaries of the nerve roots. Spine 20:138-143.CSAG (1994). Report of a Clinical Standards Advisory Croup Committee on back pain, HMSO, London.Davidson, RI, Dunn, DJ and Metzmaker, JN (1981). The shoulder abduction test in the diagnosis ofradicular pain in cervical extradural compression monoradiculopathies. Spine S: 441-446.Devor, M (1994). The pathophysiology of damaged peripheral nerves. In: Wall, PD and Melzack, R(Eds) Textbook of Pain, 3rd edn, pp. 79-100. Churchill Livingstone, Edinburgh.Devor, M (1996). Pain mechanisms and pain syndromes. In: Campbell, JN (Ed) Pain 7 996-An updatedreview. Refresher course syllabus, pp. 103-112.1ASP Press, Seattle.Durkan, JA (1991). A new diagnostic test for carpal tunnel syndrome. J Bone joint Surg IAm] 73A:53S538.Ehni, B, Ehni, C and Patterson, RH (1990). Extradural spinal cord and nerve root compression frombenign iesions of the cervical area. In: Youmans, JR (Ed) Neurological Surgery, pp. 2878-2916. Saundeis,Philadelphia.Ellenberg, MR, Honet, J C and Treanor, WJ (1994). Cervical Radiculopathy. Archives of Physical Medi-cine and Rehabilitation 75: 342-352.Farmer, JC and Wisneski, RJ (1994). Cervical spine nerve root compression. An analysis ofneuroforaminal pressures with varying head and arm positions. Spine 19:1850-1855.Fast, A, Parikh, S and Marin, E (1989 ). The shoulder abduction relief sign in cervical radiculopathy .Arch-Phys-Med-Rehabil 70: 402-3 .Cifford, LS (1997a). Neurodynamics. In: Pitt-Brooke (Ed) Rehabilitation of Movement: Theoreticalbases of clinical practice, pp. 159-195. Saundeis, London.Cifford, LS (1997b). Pain. In: Pitt-Brooke (Ed) Rehabilitation of Movement: Theoretical bases of clinicalpractice, pp. 196-232. Saundets, London.Cifford, LS (1998). Pain mechanisms and whiplash. In: Gifford, LS (Ed) Physiotherapy Yearbook No.l,NOI Press, Falmouth - In Press.Cifford, LS (1998b). Pain, the tissues and the nervous system: A conceptual model. Physiotherapy 84:27-36Gifford, LSand Butler, DS (1997). The integration of pain sciences into clinical practice. Hand Therapy10: 86-95.asue, M (1993). Pain and the nerve • (root An interdisciplinary approach. Spine 18: 2053-2058.Howe,JF, Loeser,JD and Calvin, WH (1977). Mechanosensitivity of dorsal root ganglia and chronicallyinjured axons: a physiological basis for the radicular pain of nerve root compression. Pain 3: 25-41.


Janig, W and Stanton-Hicks, M (1996). Reflex Sympathetic Dystrophy: A reappraisal, IASP Press,Seattle.Johnson, Ml (1997). The physiology of the sensory dimensions of clinical pain. Physiotherapy 83:526-536.Koltzenburg, M (1996). Afferent mechanisms mediating pain and hyperalgesia in neuralgia. In: Janig,W and Stanton-Hicks, M (Eds) Reflex Sympathetic Dystrophy: A reappraisal, pp. 123-150. IASP Press,Seattle.Kuslich, SD, Ulstrom, CLand Michael, CJ (1991). The tissue origin of low back pain and sciatica: areport of pain response to tissue stimulation durinfoperations on the lumbar spine using local anaes-thesia. Orthopaedic Clinics of North America 22:181.Maigne, JV and Deligne, L (1994). Computed tomographic follow-up study of 21 cases of non-operatively treated cervical intervertebral soft disc herniation. Spine 19:189-191.Maitland, COM (1986). Vertebral Manipulation, 5th edn, Butterworth, London.McCarron, RF, Wimpee, MW, Hudgins, PC and Laros, CS (1987). The inflammatory effect of nu-cleus pulposus: a possible element in the pathogeneses of low back pain. Spine 12: 760-764.Nathan, H and Feuerstein, M (1970). Angulated course of spinal nerve roots, lournal of Neurosurgery32: 249-352.Neary, D, Ocha, J and Cilliatt, RW (1975 ). Subclinical entrapment neuropathy in man. Journal ofthe neurological Sciences 24: 283-298.Olmarker, K, Blomquist, J, Stromber, J, Nannmark, U, Thomsen, P and Rydevik, B (1995).Inflammatogenic properties of nucleus pulposus. Spine 25: 665-669.Olmarker, K, Rydevik, B, Holm, S and Bagge, U (1989). Effects of experimental graded compressionon blood flow in spinal nerve roots. A vital microscopic study on the porcine cauda equina. Journal ofOrthopaedic Research 7: 817-823.Olmarker, K, Rydevik, B and Nordborg, C (1993). Autologous nucleus pulposus induces neurophysi-ologic and histologic changes in porcine cauda equina nerve roots. Spine 18:1425-32.Penning, L (1992). Functional pathology of lumbar spinal stenosis (review). Clinical Biomechanics 7:3-17.Penning, L and Wilmink, JT (1981). Biomechanics of lumbosacral dural sac. A study of flexion-extension myelography. Spine 6: 398.Saal, JS (1995). The role of inflammation in lumbar pain. Spine 20:1821 -1827.Spurting, RG and Scoville, WB (1944). Lateral rupture of the cervical intervertebral disc. Surgery,Gynaecology and Obstetrics 78: 350-358. *Viikari-Juntura, E (1987). Interexaminer reliability of observations in physical examinations of theneck. Physical Therapy 67:1526-1532.Viikari-Juntura, E, Porras, M and Laasonen, E (1989). Validity of clinical tests in the diagnosis of rootcompression in cervical disc disease. Spine 14: 253-7.Yoo, J U, Zou, D, Edwards, T, Bayley, J and Yuan, HA (1992). Effect of cervical spine motion on theneuroforaminal dimensions of human ceivical spine. Spine 17:1131.

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